Impact of stent strut link location in proximal balloon edge dilation technique for bifurcation percutaneous coronary intervention.

The single-stent strategy has generally been accepted as the default approach to bifurcation percutaneous coronary intervention. We have proposed the proximal balloon edge dilation (PBED) technique to prevent stent deformation during side branch (SB) dilation. This bench study aimed to evaluate the impact of stent link location and stent design on stent deformation, obstruction by stent struts at a jailed SB ostium, and incomplete stent apposition in the proximal optimization technique (POT)-PBED procedure. A coronary bifurcation model was used. We intentionally set the absence or presence of stent link on the carina (link-free or link-connect) under videoscope observation and compared stent parameters between 3- and 2-link stents (n = 5 each, n = 20 total). In the link-free group, the SB jailing rate of 3-link stents was significantly higher than that of 2-link stents (15.5 ± 5.1% vs. 6.6 ± 1.2%, p = 0.009). In the link-connect group, the SB jailing rate of 3-link stents was significantly lower than that of 2-link stents (30.0 ± 4.5% vs. 39.0 ± 2.6%, p = 0.009). In the bifurcation segment, the rate of incomplete stent apposition was significantly lower for 3-link stents of the link-connect group than for 2-link stents of the link-connect group (3.3 ± 4.2% vs. 19.0 ± 7.8%, p = 0.009). For both stent designs, ellipticity ratio was higher for link-connect group than link-free group. Link location as well as stent cell design greatly impacted stent deformation during the POT-PBED procedure.

Efficacy of Optical Coherence Tomography-Guided Primary Percutaneous Coronary Intervention in Patients with Acute Coronary Syndrome.

Background: Optical coherence tomography (OCT) is currently used as a guide for percutaneous coronary intervention (PCI), however its clinical benefit in comparison with intravascular ultrasound (IVUS) remains unclear in patients with acute coronary syndrome (ACS). Objectives: The purpose of this study was to evaluate the clinical efficacy of OCT-guided PCI in comparison with IVUS-guided PCI in patients with ACS. Methods: The study participants comprised 280 consecutive ACS patients who underwent primary PCI for de novo culprit lesions under OCT or IVUS guidance. Results: Compared with the IVUS-guided group, the OCT-guided group had lower Killip classification (p < 0.001) and lower creatinine level at baseline (0.80 ± 0.37 mg/dl vs. 1.13 ± 1.29 mg/dl, p = 0.004). Fluoroscopy time and total procedure time were significantly shorter in the OCT-guided group than in the IVUS-guided group (32 ± 13 min vs. 41 ± 19 min, p < 0.001, and 98 ± 39 min vs. 127 ± 47 min, p = 0.002, respectively). The major adverse cardiovascular event-free survival curves were similar between the OCT- and IVUS-guided groups after adjusting for clinical background using propensity score (log-rank p = 0.328). Conclusions: After adjusting for clinical background, OCT-guided PCI could provide comparable clinical outcomes to IVUS-guided PCI in patients with ACS. Shorter fluoroscopy time and total procedure time with OCT may reduce patient radiation exposure and also improve hospital workflow.

Clinical Characteristics and Outcomes of Patients Presenting With Acute Myocardial Infarction Without Cardiogenic Shock.

BACKGROUND: Most patients with acute myocardial infarction (AMI) present in the emergency department in a hemodynamically stable condition (i.e., non-cardiogenic shock) (AMI-NCS). However, few studies specifically focused on the clinical characteristics and outcomes of AMI-NCS patients. Temporal trends in clinical characteristics, in-hospital occurrence of in-hospital adverse outcomes, and the effect of primary percutaneous coronary intervention (PPCI) were examined.Methods and Results: Between April 2012 and March 2018, 176,275 AMI-NCS patients (67.7% of the total AMI population; 25.4% female; mean age 68.6±13.1 years) were identified in a nationwide Japanese administrative database. During the 6-year study period, AMI-NCS patients have been getting older and had an increasing burden of comorbidities. The rates of 30-day all-cause mortality and in-hospital complications were 2.6% and 30.5%, respectively. Thirty-day all-cause mortality did not change significantly over time, whereas in-hospital complications, especially major non-cardiac events, increased progressively. On multivariable analyses, higher age, higher Killip class, atrial fibrillation, chronic renal failure, and malignancy were independently associated with both increased 30-day mortality and in-hospital complications. PPCI was independently associated with lower mortality and in-hospital complications. CONCLUSIONS: The clinical background of AMI-NCS patients has been becoming more complex with increasing age and the burden of comorbidities, with increased in-hospital complications. More active and appropriate application of PPCI may further decrease adverse events and improve survival of AMI-NCS patients.

Resources for cardiovascular healthcare associated with 30-day mortality in acute myocardial infarction with cardiogenic shock.

Aims: Although primary percutaneous coronary intervention (PCI) and mechanical circulatory support (MCS), such as extracorporeal membrane oxygenation (ECMO) or intra-aortic balloon pumping (IABP), have been widely used for acute myocardial infarction (AMI) patients with cardiogenic shock (AMICS), their in-hospital mortality remains high. This study aimed to investigate the association of cardiovascular healthcare resources with 30-day mortality in AMICS. Methods and results: This was an observational study using a Japanese nationwide administrative data (JROAD-DPC) of 260 543 AMI patients between April 2012 and March 2018. Of these, 45 836 AMICS patients were divided into three categories based on MCS use: with MCS (ECMO with/without IABP), IABP only, or without MCS. Certified hospital density and number of board-certified cardiologists were used as a metric of cardiovascular healthcare resources. We estimated the association of MCS use, cardiovascular healthcare resources, and 30-day mortality. The 30-day mortality was 71.2% for the MCS, 23.9% for IABP only, and 37.8% for the group without MCS. The propensity score-matched and inverse probability-weighted Cox frailty models showed that primary PCI was associated with a low risk for mortality. Higher hospital density and larger number of cardiologists in the responsible hospitals were associated with a lower risk for mortality. Conclusion: Although the 30-day mortality remained extremely high in AMICS, indication of primary PCI and improvement in providing cardiovascular healthcare resources associated with the short-term prognosis of AMICS.

Outcomes of Venoarterial Extracorporeal Membrane Oxygenation Plus Intra-Aortic Balloon Pumping for Treatment of Acute Myocardial Infarction Complicated by Cardiogenic Shock.

Background Clinical outcomes of acute myocardial infarction complicated by cardiogenic shock remain poor with high in-hospital mortality. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been widely used for patients with acute myocardial infarction complicated by cardiogenic shock refractory to conservative therapy, which is likely fatal without mechanical circulatory support. However, whether additional intra-aortic balloon pumping (IABP) use during VA-ECMO support improves clinical outcomes remains controversial. This study sought to investigate prognostic impact of the combined VA-ECMO plus IABP treatment compared with VA-ECMO alone. Methods and Results From the nationwide Japanese administrative case-mix Diagnostic Procedure Combination (DPC), the JROAD (Japanese Registry of All Cardiac and Vascular Diseases)-DPC, we identified 3815 patients with acute myocardial infarction complicated by cardiogenic shock who underwent primary percutaneous coronary intervention and managed with VA-ECMO. Of these, 2964 patients (77.7%) were managed with IABP (VA-ECMO plus IABP), whereas 851 (22.3%) were managed without IABP (VA-ECMO alone). We compared in-hospital, 7-day, and 30-day mortality between the VA-ECMO plus IABP versus the VA-ECMO alone support. Patients managed with VA-ECMO plus IABP demonstrated significantly lower in-hospital, 7-day, and 30-day mortality than those managed with VA-ECMO alone (adjusted odds ratios [95% CI] of 0.47 [95% CI, 0.38-0.59], 0.41 [95% CI, 0.33-0.51], and 0.30 [95% CI, 0.25-0.37], respectively). The findings were consistent in the propensity matching and inverse probability of treatment-weighting models. Conclusions This large-scale, nationwide study demonstrated that the combination of VA-ECMO plus IABP support was associated with significantly lower mortality compared with VA-ECMO support alone in patients presenting with acute myocardial infarction complicated by cardiogenic shock who underwent primary percutaneous coronary intervention.

Bifurcation percutaneous coronary intervention of left main trunk treated using a proximal optimizing technique and proximal balloon edge dilation technique.

We present a case of bifurcation percutaneous coronary intervention (PCI) of the left main trunk (LMT) using a proximal balloon edge dilation (PBED) technique following a proximal optimizing technique (POT). The procedure of the PBED technique entailed precise positioning of the balloon for SB dilation, with the proximal radiopaque marker lying in the cross-sectional plane of the stent struts at the left circumflex artery (LCx) ostium. The PBED technique might prevent stent deformation induced by side branch (SB) dilation and eliminates the need for the second POT procedure in the re-POT sequence. In fact, three-dimensional reconstruction of optical coherence tomography (3D-OCT) revealed good opening of stent cells overlying the LCx ostium without deformation of stent struts causing incomplete stent apposition at the site opposite the LCx, so the second POT procedure was unnecessary in this case. .

Differences in preoperative function and outcome of patients with versus without sarcopenia after total hip arthroplasty.

[Purpose] Public attention regarding sarcopenia has increased in recent years. Patients with sarcopenia reportedly show worse return home rates and activities of daily living at discharge. However, no reports have described the function and outcomes of hip osteoarthrosis patients with sarcopenia after total hip arthroplasty. This study aimed to clarify differences in preoperative physical function and outcomes of hip osteoarthrosis patients with versus without sarcopenia after total hip arthroplasty. [Participants and Methods] Twenty-five patients with hip osteoarthrosis who underwent total hip arthroplasty were included. Evaluation items were preoperative skeletal muscle mass of the extremities, isometric strength of the lower extremities (hip abduction and knee extension), grip strength, and the 10-m timed gait test results. [Results] The prevalence of sarcopenia was 8% (2/25 patients). The sarcopenic group displayed lower skeletal muscle mass index, grip strength, and 10-m timed gait test values. The sarcopenic group showed lower muscle mass in the upper and lower limbs and trunk and lower hip abductor strength than the non-sarcopenic group. [Conclusion] Eight percent of patients developed sarcopenia after total hip arthroplasty. Due to the low average age (66.0 ± 9.5 years), the prevalence was lower than that of other orthopedic diseases.

Impact of Coronary Stent Design in Proximal Balloon Edge Dilation Technique for Bifurcation Percutaneous Coronary Intervention.

The proximal optimizing technique (POT) -proximal balloon edge dilation (PBED) sequence for side branch (SB) dilatation with cross-over single-stent implantation decreases both strut obstruction at the SB ostium and stent deformation at the main branch (MB).The purpose of this experimental bench test was to assess the impact of stent design on stent deformation, obstruction by stent struts at a jailed SB ostium, and stent strut malapposition in the POT-PBED sequence.Fractal coronary bifurcation bench models (60- and 80-degree angles) were used, and crossover single-stent implantation (3-link stent: XIENCE Sierra, Abbott Vascular, Santa Clara, CA, n = 10; 2-link stent: Synergy, Boston Scientific, Marlborough, MA, n = 10) was performed from the MB using the POT-PBED sequence. Jailing rates at the SB ostium, stent deformation, and stent strut malapposition of the bifurcation segment were assessed using videoscopy and optical coherence tomography.After SB dilatation using the PBED technique, jailing rates at the SB ostium and stent deformation did not differ significantly between the two types of stents. Conversely, the rate of malapposed struts of the bifurcation segment after the PBED procedure was significantly lower with 3-link stents than with 2-link stents for both 60- and 80-degree angles (60-degree angle: 4.3% ± 4.4% versus 22.0% ± 11.1%, P = 0.044; 80-degree angle: 20.8% ± 15.1% versus 57.2% ± 17.0%, P < 0.001, respectively).In the POT-PBED sequence, 3-link stents might be a preferable coronary bifurcation stent, maintaining a jailed SB ostium while significantly reducing stent strut malapposition of the bifurcation segment when compared with 2-link stents.

Acute coronary syndrome demonstrating plaque rupture in calcified plaque visualized by optical coherence tomography and near-infrared spectroscopy combined with intravascular ultrasound.

Optical coherence tomography (OCT) can visualize calcification of the coronary plaque as a low-intensity lesion with sharp borders. However, residual lipid tissue inside the calcification could pose a problem in plaque evaluation by OCT. We present a case of acute coronary syndrome (ACS) demonstrating plaque rupture in the calcified plaque. In this case, OCT demonstrated a cavity suspected to represent rupture in the calcified plaque and near-infrared spectroscopy revealed a lipid component behind the calcified plaque. Although calcified plaque is not considered a reason for ACS except for calcified nodules, residual lipid tissue inside the calcification might cause ACS if the thin fibrous cap over the lipid tissue is disrupted, even if surrounded by calcification. .